| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
451 |
451 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
384 |
384 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
664 |
663 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
293 |
293 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
940 |
930 |
$3K |
| D0274 |
Bitewings - four radiographic images |
198 |
197 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$652.50 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$292.00 |